Surgical resection is currently the gold standard in operable patients with early-stage lung cancer. Video-assisted thoracoscopic surgery (VATS) lobectomy is a technique that has technically evolved and grown increasingly popular over the past two decades. This article presents the evolution, definition, current application, and some of the controversies surrounding VATS lobectomy.
Key Points
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Video-assisted thoracoscopic surgery (VATS) lobectomy is now emerging as the standard of care for resectable early-stage lung cancer.
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VATS lobectomy has equivalent or improved short-and long-term outcomes compared with open approaches.
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VATS lobectomy should be incorporated into thoracic oncologic practices in a stepwise, organized manner.
Videos of ‘ video assisted thoracoscopic surgery lobectomy ’ accompany this article at http://www.surgonc.theclinics.com/.
Video-assisted thoracoscopic surgery lobectomy-pioneering efforts and fundamental basis in thoracoscopy
Thoracoscopic surgery has been a critical advancement in the care of patients with intrathoracic disease. Initially introduced for diagnostic or minor pleural operations, thoracoscopic surgery has a long history. Early pioneers adapted surgical tools used in endoscopy and urologic surgery for thoracoscopy for a variety of conditions, including gunshot wounds; however, the technique was not widely adopted. In 1910, a Swedish internist, Jacobaeus, used a trocar and cannula to induce artificial pneumothorax in a female patient with pulmonary tuberculosis. This description popularized thoracoscopy, but little progress was made in its technical applications. Over the next 8 decades, thoracoscopic procedures remained mainly diagnostic or had limited therapeutic application. The 1990s saw major advances in video technology, microcameras, and endoscopic surgical instruments. These technological advances created the perfect milieu for pioneering surgeons to attempt advanced procedures such as lobectomy via a less-invasive thoracoscopic approach.
McKenna’s report of an initial experience with video-assisted thoracoscopic surgery (VATS) lobectomy in 44 patients in 1994 marked a significant technical advancement in thoracic oncology. In the period immediately after that report, between 1995 and 2000, VATS lobectomy was met with much skepticism, with specific concerns about the technical aspects of the procedure, its oncologic adequacy, and general reluctance in the surgical community to fundamentally change the approach to an operation. To further add to the controversy, and to provide heft to the arguments of the conservatives, 2 different technical approaches were being advocated for dividing the hilar structures, the critical aspect of a lobectomy. McKenna and other authors advocated the individual dissection and division of the pulmonary arteries, pulmonary veins, and the airway. On the other hand, Lewis reported thoracoscopic lobectomy with simultaneous stapling of the vessels and bronchus rather than individual ligation. With this technique, the lobe was initially mobilized with partial completion of the fissure. A linear stapler commonly used for open procedures was then fired across the vessels and bronchus. This procedure created much controversy, because many surgeons viewed this as a large wedge resection, whereas others were concerned about the development of bronchovascular or pulmonary arteriovenous fistulae. This latter technique is rarely performed today, suggesting that the concerns of the detractors of the mass hilar ligation technique were warranted.
Despite these early controversies, some thoracic surgeons saw a clear advantage to the minimally invasive techniques in terms of improved patient comfort and reduction of surgical trauma. By 1997, 23 surgeons had published results of more than 1500 VATS lobectomy operations. These articles mainly focused on the feasibility of the procedure and early results, with some authors reporting 5-year survival comparable to that of conventional open lobectomy.
Widespread adoption of VATS (2000–present)
Over the past decade, VATS lobectomy has evolved from an operation that only a few centers offered to the de facto preferred procedure for early-stage lung cancer. Although 97 papers were published about VATS lobectomy from 1990 to 2000, since 2000 more than 600 reports discussing this operation have been published in PubMed-indexed journals. This transition has been facilitated by 2 factors.
The first factor is the increasing technical comfort of thoracic surgeons with minimally invasive approaches. The use of a utility (minithoracotomy) incision and the associated adaptation of conventional open instruments to VATS operations have enhanced this technical comfort and enabled great strides in the advancement of minimally invasive approaches. The transition and the learning curve have been elegantly described in several reports from academic and private practice settings. The authors’ practice has seen a significant shift in the approach to patients with early-stage lung cancer. Before 2005, fewer than 15% of lobectomy operations were performed using VATS, whereas by 2009 more than 55% of lobectomies were completed thoracoscopically ( Fig. 1 ).
The second major factor that has led to the surge in VATS lobectomy has been the large volume of reports indicating its short-term superiority over and long-term oncologic equivalence to open lobectomy performed via thoracotomy. The general approach of VATS lobectomy has been the focus of a successful cooperative group feasibility study, 3 randomized trials, more than 30 nonrandomized comparative studies, and hundreds of institutional case series. Data from the Society of Thoracic Surgeons (STS) General Thoracic Surgery database for 2006 showed that 32% of lobectomies for primary lung cancer were performed via VATS, and the proportion is certainly higher now. National thoracic surgical meetings have consistently hosted didactic courses, wet laboratories, and dedicated sessions for VATS lobectomy since 2006, and thoracic surgical residency training programs must ensure adequate exposure to this operation for their trainees to remain competitive.
Current definition of VATS lobectomy
Although it is generally agreed that a thoracoscopic lobectomy should be a similar oncologic procedure to an open lobectomy and should imitate established technical principles of that operation, the definition of what constitutes a VATS lobectomy varies greatly. The term can potentially refer to a range of operations, including a standard thoracotomy and lobectomy via a smaller skin incision, or even a giant wedge resection. As an initial step to introduce uniformity to the operation and to study its application in multiple centers, the Cancer and Leukemia Group B (CALGB) 39802 prospective multi-institutional study was designed to elucidate the technical feasibility and safety of VATS in early non–small cell lung cancer (NSCLC) using a standardized definition for VATS lobectomy. The trial defined VATS lobectomy as an operation in which
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Visualization of intrathoracic structures involves the use of videoscopic equipment (as opposed to direct visualization via a minithoracotomy)
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No rib spreading occurs
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Individual dissection of the vein, arteries, and airway is performed for the lobe in question
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An access incision no longer than 8 cm is created for removal of the lobectomy specimen
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A standard node sampling or dissection (identical to an open thoracotomy) is performed
Subsequently, multiple authors have described technical variations of this outline, but this general definition of VATS lobectomy has found widespread acceptance. Some of the more common technical nuances within the broad definition of VATS lobectomy are summarized in Table 1 .
| Technique | Comment |
|---|---|
| Position | Lateral decubitus with or without table flexion, Some use slight posterior tilt |
| Number of incisions | 2–4 |
| Intrathoracic access | Direct or via thoracoscopic/laparoscopic ports |
| Carbon dioxide insufflation | Occasionally used |
| Videoscope | 0° or 30° |
| Instruments | Standard thoracotomy set or laparoscopic instruments |
| Division of vasculature | Stapled, ties, or energy device |
| Lymph nodes | Complete dissection or systematic sampling |
Outcomes
Intraoperative Issues
Bleeding from a major pulmonary vessel during VATS can be dangerous because of the limited access. However, because of the lower-pressure pulmonary vascular system, hemorrhage can nearly always be controlled through application of gentle pressure with a broad sponge stick. With the bleeding temporarily controlled, a decision is made as to whether the bleeding can be definitively controlled with VATS or a thoracotomy is needed. Even in the early experience, the incidence of major intraoperative bleeding was low. A collective report by McKenna from 2000 noted that bleeding led to the conversion to a thoracotomy in 10 of 1120 cases from 8 institutions (0.9%). No deaths resulted from the bleeding episodes, and not all patients required transfusion. Over the past decade, numerous reports have described a 0% to 5% conversion rate to thoracotomy because of intraoperative bleeding. In comparative reports, the average blood loss of VATS and open lobectomy have been similar and generally less than 250 mL. Although publication bias may lead to an underappreciation of the incidence and severity of this problem, it seems to be a manageable and generally preventable problem.
Postoperative Outcomes
Most papers comparing VATS with open lobectomy are retrospective single-institutional series and collective reports. Nevertheless, a general clear trend has been seen toward fewer perioperative complications with the VATS approach. These range from fewer postoperative arrhythmias to lower incidence of pneumonia and other respiratory complications. The perioperative mortality for VATS lobectomy is comparable to open surgery. The length of chest tube drainage and hospital stay is reduced with VATS lobectomy. A summary of these reports is presented in Table 2 .
| Author, Year | Type of Report | Approach | Number of Patients | Complications (%) | Length of Hospitalization (d) | Mortality |
|---|---|---|---|---|---|---|
| Kirby et al, 1995 | Prospective | VATS Open | 25 30 | 24 53 | 7.1 8.3 | 0 0 |
| Petersen et al, 2007 | Retrospective | VATS Open | 43 57 | 27 35 | 4 5 | 0 0 |
| Whitson et al, 2007 | Retrospective | VATS Open | 59 88 | Pneumonia: 3 19 | 6.4 7.7 | 0 0 |
| Whitson et al, 2008 | Review | VATS Open | 3114 3256 | 16.4 31.2 | 8.3 13.3 | NR NR |
| Villamizar et al, 2009 | Retrospective | VATS Open | 284 284 | 31 49 | 4 5 | 3 5 |
| Flores et al, 2009 | Retrospective | VATS Open | 398 343 | 24 30 | 5 7 | 0.3 0.3 |
| Yan et al, 2009 | Review | VATS Open | 1391 1250 | NR NR | 12 12.2 | 0.4 0.7 |
| Scott et al, 2010 | Prospective | VATS Open | 66 686 | 27 48 | 5 7 | 0 1.6 |
| Park et al, 2012 | Retrospective | VATS Open | 1523 4769 | 38 44 | 5 7 | 1.5 2.2 |
Pain Control and Quality of Life
Thoracotomy is one of the most painful surgical procedures, and some patients may also experience postoperative upper extremity dysfunction. Anatomically, the main cause of postoperative pain is direct injury to the chest wall and intercostal nerves. Rib spreading in a thoracotomy can cause uncontrolled rib fractures and impingement of intercostal nerves. The diminished surgical trauma to the chest wall from VATS lobectomy is reflected in diminished levels of postoperative pain. The shorter duration of chest tube drainage after VATS lobectomy may also contribute to the lower pain levels. More than 80% of patients still require narcotic analgesics 3 weeks after an open lobectomy compared with fewer than 40% patients after a VATS lobectomy. Reduced pain levels may contribute to the observed improved quality of life (QOL) after a VATS resection.
A 2008 report by Demmy and Nwogu provided a comprehensive review of subjective and objective QOL measures after VATS lobectomy. They reviewed 97 papers and concluded that QOL is improved compared with after open surgery, and this improvement is demonstrated by better scores on standardized QOL instruments, improved physical activity after surgery, and an earlier return to work. Additionally, this relative improvement in QOL and functional status is most marked in older patients (>70 years old), those with emphysema, and those with other significant comorbidities that increase frailty. At discharge, nearly 80% of patients who undergo VATS lobectomy are independent and do not require assistance with activities of daily living or specific nursing care, compared with 30% of those who undergo open lobectomy. Another relevant issue is the ability to tolerate adjuvant chemotherapy when indicated. A report from the Duke thoracic surgery group concluded that patients who undergo VATS lobectomy tolerate postoperative adjuvant therapy significantly better than patients who undergo open lobectomy, showing the superior preservation in performance status afforded by less-invasive surgery.
Long-Term Outcomes
The success of any oncologic procedure can only be truly measured in terms of intermediate- to long-term survival compared with the gold standard. Only a few reports presented long-term survival after VATS lobectomy in the 1990s. However, the results were favorable, with McKenna and colleagues reporting a 4.5-year survival of 76% for 212 patients with stage I lung cancer. The growing experience has been reflected in the form of larger series, with the same authors reporting on outcomes from 1100 VATS lobectomy operations in 2006. Of these patients, 497 with stage IA lung cancer had a 5-year survival of 80%. Similar outcomes for VATS lobectomy for stage I lung cancer have now been reported by several other authors, and these are summarized in Table 3 .
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